BlueCross BlueShield of Tennessee Medical Policy Manual

Serum Tumor Markers for Gastrointestinal Cancer

DESCRIPTION

Serum tumor markers are substances produced by cells in response to cancer or certain noncancerous conditions. Most tumor markers are made by normal cells as well as cancer cells; however, they are produced at much higher levels in cancerous conditions. These substances can be found in blood, urine, stool, tumor tissue, or other tissues or bodily fluids.

Carcinoembryonic antigen (CEA) is a glycoprotein found in high levels in those individuals with colorectal cancers (CRC). CEA is used to monitor response to treatment and to detect disease recurrence. CA 19-9 monitors recurrence or metastases in pancreatic cancer.

POLICY

Serum tumor markers for the treatment of gastrointestinal cancer are consideredmedically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Serum tumor markers for the treatment of other gastrointestinal cancers are considered investigational.

The use of serum tumor markers is considered medically appropriate if ANY ONE of the following are met:

CA 19-9 is indicated when ALL the following are met:

In the management of pancreatic adenocarcinoma

Postoperatively to assess for recurrence or metastatic disease

Prior to initiation of adjuvant therapy

Carcinoembryonic antigen (CEA) testing is indicated for ALL of the following:

In the management of colorectal cancer as indicated by ANY ONE of the following:

Preoperatively to assist in staging and surgical planning

Postoperative baseline

Postoperative follow-up interval of ANY ONE of the following:

First two years post resection, every three to six months

Three to five years post resection, every six months

Follow-up CEA testing not to exceed five years post resection

IMPORTANT REMINDERS

Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

Current data are insufficient to recommend additional biomarkers, such as CA 72 and CA 125 for screening, diagnosis, staging, surveillance or monitoring treatment of individuals with colorectal cancer. CA 19-9’s low positive predictive value makes it a poor biomarker for pancreatic cancer screening. CEA is not recommended as a screening test for colorectal cancer.

SOURCES

American Society of Clinical Oncology. (2006). Update of recommendations for the use of tumor markers in gastrointestinal cancer. Retrieved August 9, 2016 fromwww.jco.ascopubs.org.

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.